HIM Specialist II

MedStar Health
United States, D.C., Washington
Nov 18, 2024
General Summary of Position Performs clerical duties related to maintenance, processing and completion of medical records. Responsible for assuring that all patient records and loose documents are placed/scanned into the Electronic Medical Record with the highest level of quality possible. Responsible for indexing all documents to the appropriate patient folder and ensuring that each document is assigned the appropriate document name. Processes release of information to patients, attorneys and third-party payers. Processes transcribed documents. Primary Duties and Responsibilities Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations. Performs deficiency analysis of patient medical records to ensure compliance with JCAHO standards, DOH regulations, state and federal statutes, and Hospital policy and procedures. Performs quantitative and qualitative review, verifies physician signature, and the presence of key reports such as history and physical and discharge summaries in the medical record(s). Selects appropriate assignments from analysis task queue on a daily basis. Assists providers on dictation and transcription problems. Validates the data integrity and reliability of transcribed patient reports. Identifies and assigns deficient medical records/charts to appropriate medical staff member for completion. Enters deficiencies and physician assignments into the department's computer system. Performs a process of re-analysis of patient medical record to ensure all deficiencies have been completed by the medical staff. Serves as a resource for clinicians with questions regarding completion of deficiencies in the electronic record (including Cerner message center) Assists providers when problems arise following assignment of deficiencies, including daily monitoring of Physician Refusal Inbox. Assists in suspension process according to policy and procedure. Contacts provider offices to follow-up prior to actual suspension dates. Handles removing providers from suspension status (notifications, system updates, etc.) Tracks medical record(s) via the department computer system to show the current location, e.g. desk, shelf, Incomplete Files. Retrieves records from unit and perform scanning process according to procedure and within established time frame. Reviews and indexes all scanned images within 24 hours of initial scanning. Identifies documents that are of poor quality and rescans documents accordingly. Ensures that all scanned documents are positioned correctly and fixes those that are not correct. Performs scanning indexing process with accuracy :Each document is indexed to the correct patient/encounter; Each document is assigned the correct document name; Verifies that bar-coded documents are correctly indexed. Assists with monitoring and entering patient diagnosis codes into computer system. Monitors and provides delinquent coding accounts lists to remote coder. Reviews medical record to ensure all clinical and demographic data pertaining to a specific patient is maintained under one medical record number to ensure that safety of the patient medical records. Assists with reviewing and processing authorized release of information requests for patient information that are consistent with Hospital policies and federal regulations. Participates in multidisciplinary quality and service improvement teams as appropriate. Participates in meetings, serves on committees and represents the department and hospital/facility in community outreach efforts as appropriate. (Especially Release of Information and Document Imaging). Minimum Qualifications Education High School Diploma or GED required Associate's degree in Health Information Management technology preferred or equivalent education and experience in a health information management department preferred Experience Experience in hospital health information management or related experience preferred Licenses and Certifications Registered Health Information Technician preferred Knowledge, Skills, and Abilities Excellent Verbal and written communication skills; Basic computer skills required; Medical Terminology is required This position has a hiring range of $18.33 - $31.61